Dermatological Manifestations of COVID-19 in Patients Reporting to a Tertiary Care Hospital in Rawalpindi, Pakistan

Introduction The clinicopathological description of dermatological manifestations of COVID-19 leaves much to be desired. There is a need to determine their association with disease severity, outcome, and other clinical variables. Objectives The objectives of this study are to record and histopathologically examine the cutaneous manifestations of COVID-19 and correlate these to age, disease severity, and mortality. Methods All confirmed COVID-19 patients admitted to a single tertiary healthcare hospital in Rawalpindi, Pakistan, were included. Their diseases were classified as mild, moderate, severe, and critical. The recent onset skin eruptions in these patients were recorded via photographs along with relevant clinical data. The photographs were independently reviewed by a group of three dermatologists without knowledge of the clinical information. The skin manifestations were divided into disease-specific and nonspecific categories using an already defined algorithm. Histopathological examination of skin manifestations was conducted. Results A total of 23% (n=47) had “new” skin manifestations. Specific skin findings were seen in 21.6% (n=44), which consisted of ecchymosis/purpura in 50% (n=22), maculopapular exanthem in 18% (n=8), livedo reticularis in 16.2% (n=7), ischemia/gangrene in 16.2% (n=7), perniosis in 15.9 % (n=7), vesiculo-bullous rash in 9% (n=4) and urticaria in 4% (n=1). Non-specific findings were seen in 6% (n=13) and included bedsores, dermatitis passivata, dryness, herpes labialis, oral ulcerations, and nasogastric tube-induced ulcerations. There was a significant association (p=0.03) between disease severity and specific skin lesions. Ischemia/gangrene was significantly associated with COVID-19 disease severity and mortality. Vesiculobullous lesions were associated with higher mortality, though not with disease severity. Livedo reticularis had a higher-than-expected count in critical disease, albeit statistically insignificant. The association of maculopapular exanthem and ecchymosis/purpura with severe/critical disease was statistically insignificant. Urticaria was significantly associated with low disease severity. Mean age with specific manifestations was 56.86 ± 15.81 and with nonspecific/without any manifestations was 42.58 ± 16.96, a highly significant difference, with p-value < 0.001. Old age (>60 years) was significantly associated with ecchymosis (p=0.038), maculopapular exanthem (p=0.021), and vesiculo-bullous rash (p=0.029). Histopathology varied according to the type of skin lesion. Conclusions Dermatological manifestations coexist in many patients and tend to appear more in severe cases of COVID-19 among the older age group and only minimally in mild/moderate cases. Their presence could help set prognostic criteria of COVID-19 disease in the future.


Introduction
was first detected in the Chinese city of Wuhan in December 2019 as pneumonia that involved multiple organ systems [1]. The newfound virus would promptly spread across swaths of the planet and be declared a global pandemic shortly after.
As part of the multisystem involvement that COVID-19 encompasses [2], the skin can exhibit various manifestations. Descriptions of the cutaneous manifestations of COVID-19 have been attempted by various studies across the globe showing fluctuating frequency, types, extent, and association to the disease severity. The frequency of dermatological manifestations may vary from 0.2% to 20.4% [2][3][4][5]. These include maculopapular exanthem, urticarial, vesicular/bullous, perniosis ecchymosis/purpura, livedo reticularis, acral ischemia/gangrene, and maculopapular rash with enanthem. COVID-19 may also cause non-specific dermatological manifestations that result from various treatment sequelae, prolonged in-hospital care, and poor skin hygiene of patients [6,7] while being isolated for extended durations.
The limitations of these studies were variable; some were individual case studies, while others had small sample sizes [8,9] or lacked adequate pictorial data [10] due to safety concerns related to the highly contagious virus [3]. Even fewer studies performed the histological examination of the lesions.
Our study attempts to corroborate the previously detailed classifications and descriptions of the cutaneous manifestations of COVID-19, describes their histological features, and attempts to relate them with age, disease severity, and mortality.

Materials And Methods
All confirmed COVID-19 patients (with laboratory confirmation of SARS-CoV-2, irrespective of the severity of their clinical signs and symptoms) admitted in a tertiary inpatient health care facility in Rawalpindi, Pakistan were included. All patients who showed recent-onset skin eruptions were included. Their diseases were classified as mild, moderate, severe, and critical as per WHO guidelines [11].
This descriptive study was conducted in July 2020 for a duration of one month. A specially designed form was used for data collection and pictures were taken of all the skin manifestations using full personal protective equipment protocol.
The photographs were independently reviewed by a group of three dermatologists without knowledge of the clinical information. The skin lesions were then classified using an algorithm for the classification of cutaneous manifestations of COVID-19 [12]. Analysis of descriptive data and distribution tests was done using SPSS Statistics 23 (IBM Corp., Armonk, NY).
The study was approved by an ethical committee (A/28/180/EC/2020). All patients, or their next of kin in case of minors/critically ill, gave their informed consent to participate and explicit consent to use their pictures in publications and perform biopsies when needed.
Complete blood picture including eosinophilic counts was performed to rule out the possible association of the skin manifestations with the drugs administered during the treatment. Histopathological analysis was carried out on biopsies.
Around 50% (n=4) of maculopapular exanthem and 65% (n= 13) of ecchymosis/purpura were seen in severe or critical cases. However, the statistical analyses of both these lesions were non-significant in relation to disease severity and mortality. Urticaria was significantly associated with low disease severity ( Table 2).
The mean age of patients with specific skin manifestations was 56.86 ± 15.81, while that of patients either with nonspecific/without any skin manifestations was 42.58 ± 16.96. This difference is highly significant, with a p-value < 0.001 (independent samples t-test). Analysis of age against individual specific skin manifestation shows that old age (>60 years) is significantly associated with ecchymosis (p=0.038), maculopapular exanthem (p=0.021), and vesiculobullous rash (p=0.029). Age showed no association with ischemia/necrosis, livedo reticularis, perniosis or urticaria (p=0.067, 0.992, 0.335, and 0.542, respectively) (  Histopathological examination of livedo reticularis, in one sample, showed fibrinoid necrosis, vascular congestion, extravasation of RBCs and mild perivascular lymphocytic infiltration in the papillary dermis, consistent with lymphocytic vasculitis, while the lower dermis was unremarkable ( Figure 5). Five samples exhibited hyperkeratosis, hypergranulosis and perivascular lymphocytic infiltration in the upper dermis. Biopsy couldn't be performed in one case.

RBCs and mild perivascular lymphocytic infiltration in papillary dermis, consistent with lymphocytic vasculitis. H&E stain, 10x magnification
Five samples exhibited hyperkeratosis, hypergranulosis, and perivascular lymphocytic infiltration in the upper dermis. Biopsy couldn't be performed in one case. In the case of maculopapular rash, one biopsy manifested orthokeratosis and the dermis had perivascular lymphocytic infiltration with collagen fibers separated by mucinous material (mucinous degeneration of dermis). In another sample, orthokeratosis, thinning of the epidermis with loss of rete ridges along with perivascular lymphocytic infiltration with RBC extravasation in the dermis, was seen ( Figure 6).

H&E stain, 10x magnification
Three samples showed mild perivascular lymphocytic infiltration in the dermis. Biopsies couldn't be performed in the rest of the three cases. In a sample of necrotic plaque, the epidermis showed follicular plugging, mild acanthosis, increased basal pigmentation and vacuolated keratinocytes. There was dermal edema with congested blood vessels and extensive RBC extravasation throughout the dermis. The biopsy of bullous/blister tissue from one patient manifested hyperkeratosis with the underlying necrotic epidermis separated from dermis via a sub-epidermal blister. The dermis revealed perivascular lymphocytic infiltration (Figure 7). Figure   1, showing hyperkeratosis with underlying necrotic epidermis, separated from dermis via a sub-epidermal blister. The dermis showed perivascular lymphocytic infiltration. H&E stain, 10x magnification.

FIGURE 7: Biopsy of bullous/blister tissue from patient shown in
Another sample of tense blisters on the face and limbs showed focal areas of epidermal necrosis attached to the underlying dermis, which in turn had acute on chronic inflammatory infiltration (Figure 8).

FIGURE 8: Biopsy of an ischemic plaque on forearm, epidermis show mild acanthosis, increased basal pigmentation and vacuolated
keratinocytes. There is dermal edema with congested blood vessels and extensive RBCs extravasation throughout the dermis. H&E stain, 40x magnification.
Histopathological examination was not done for ecchymosis/purpura, perniosis, urticaria and nonspecific skin manifestations.

Discussion
Our study chronicles several cutaneous patterns associated with COVID-19, indicating that a considerably large group of patients may have dermatological manifestations, appearing at different instances in the course of disease at varying levels of severity, likely contributing to defining the prognosis of the disease. The description of certain histological patterns in our study may further enhance our knowledge about these manifestations. With a large number and distribution of participants, all of them testing positive for COVID-19, our sample is truly representative of the distribution of cutaneous lesions in COVID-19. Our attempt to describe the skin lesions in patients with mild to critical disease, as well as exclusion of suspected patients and testing for other respiratory viruses, reduced the chances of a bias in the results further. It is possible that some of the specific findings may have causes other than COVID-19, an example being clexane-induced ecchymosis. We tried to rule out those via carefully tracking history and examinations where an alternate cause could be suspected. Drug-induced rashes were ruled out by tracking history, careful analysis of the cutaneous findings, and performing peripheral eosinophil counts as well biopsies where feasible.
The majority of the cutaneous manifestations we observed appeared late in the course of the disease. One of the possible mechanisms behind this could be a delayed immune-mediated reaction to the virus in genetically predisposed individuals [13,14].
Ecchymosis/purpura in the majority of patients appeared late in the disease course (second week or beyond) making it an unusable clinical feature in early diagnosis of COVID-19. We found a significant association of these lesions with a higher age group, not reported by earlier studies, to the best of our knowledge. Though statistically insignificant, two-thirds of these lesions were seen exclusively in severe/critical cases. Unlike a Turkish study [15] we noted a possible connection of ecchymosis/purpura with COVID-19 induced thrombocytopenia in 22.7% (n=5/22) patients, who had thrombocytopenia without clexane administration. Thrombocytopenia itself may be associated with a high risk of severe COVID-19 disease and mortality [16] thus serving as a clinical indicator of worsening disease during hospitalization. Other unexplained mechanisms involving vascular damage possibly via immune dysregulation, vasculitis, or thrombosis [17,18] could be implied in 13.6% (n=3/22) of ecchymosis/purpura patients, who neither had thrombocytopenia nor clexane.
Maculopapular lesions tend to concur with other symptoms appearing in the first or the second week of illness. We found a statistically significant association of old age (>60 years) with the presence of a maculopapular rash. This was consistent with a systemic review [19] which noted the mean age of patients with maculopapular rash to be 60.4 years. In contrast to a Spanish study [20], we didn't find these lesions to be either exclusive to severe/critical disease or associated with any mortality in our sample. Histopathological features of maculopapular lesions in our study are somewhat consistent with descriptions provided by earlier case reports of such lesions [21,22].
Contrary to others [13], we found a higher incidence of livedo reticularis in our COVID-19 disease sample. The rash appeared in the first week of illness in most cases. Consistent with a Spanish study [20], mostly elderly patients manifested such findings in our sample. A higher than expected number of livedo reticularis patients presented with severe/critical COVID-19 disease. Although statistical significance was not found, further research is warranted to ascertain the above-mentioned relationship. Livedo reticularis may either be the primary manifestations of the disease or may point towards complications leading to vascular occlusion, as COVID-19 has already been linked to coagulation anomalies and vascular damage [23]. The presence of fibrinoid necrosis in papillary dermal vessels with congestion, RBC extravasation, and mild perivascular lymphocytic infiltration in a biopsy of livedo reticularis in our study, further augments this treatise. Livedo reticularis also exhibited hyperkeratosis, epidermal hyperplasia, hypergranulosis, and perivascular lymphocytic infiltration with RBC extravasation in the upper dermis in five biopsy specimens. A systemic study that compiled a histological description of livedo reticularis rash by Li et al. [13] reported similar histological findings. Livedo reticularis may help raise suspicion of COVID-19 as it appears earlier in the disease course, thus helpful in its diagnosis, albeit in a minority.
Pseudo-chilblain appears like perniosis. Considering that they customarily appear in July's warm weather, with the average high temperature being 35.7⁰C [24], a noteworthy increased incidence as perceived by dermatologists, all patients being COVID-19 positive and with no previous history of such lesions, a COVID-19 link becomes highly plausible. The findings are consistent with other studies that reported perniosis-like lesions in 318 cases from eight countries [25], negating some earlier assumptions that considered these lesions to be induced by cold temperature and immobility [8]. Pseudo-chilblains appeared later, either alone or in combination with ischemic/blistering lesions in our sample. Consistent with a Spanish study [20], their association with disease severity was statistically insignificant.
Ischemic/gangrenous lesions appeared late in the disease course, involving fingers, digits, and even whole limbs (n=2) or forearm skin (n=2) in some cases. Unlike previous studies [20], we think that these dry gangrenes could appear at any age and are particularly high in severe/critical cases. Our research correlates these findings with a bad prognosis and high mortality as reported by other limited-scale observations [26]. The presence of ischemia/gangrene in COVID-19 disease considerably augments the concept of a synergy between vasculitis and hypercoagulable states induced by COVID-19, as reported in earlier studies [9,27].
Vesiculo bullous lesions might appear early or later in the disease course. They were significantly associated with higher mortality (n=3/9) in our cohort. We found no studies that correlated these lesions to COVID-19 mortality. Though statistically insignificant, we observed these to be far more frequent in severe/critically ill patients. Their incidence was far less compared to other skin manifestations in our study.
Consistent with a previous study [20], we think that urticarial lesions may be accredited to many causes. They do not predate other symptoms and hence, are unhelpful in making a diagnosis.
Apart from offering specific systemic therapy to treat COVID-19, clinicians and nursing staff should also give attention to maintaining general skin health and hygiene, to prevent and treat non-COVID-19 related skin issues such as dermatitis passivata, bedsores, xerosis, oral ulcers, and nasogastric tube induced ulcers [6,7]. As observed in our study, a lot of patients, due to a lack of knowledge regarding this novel disease, didn't know whether to follow the usual skincare routine and take showers or not. COVID-19 patients are especially prone to have neglected skin hygiene due to prolonged and isolated in-hospital stays where patient and care provider interaction is minimal due to the highly infectious nature of the virus.
COVID-19 appears to be an unusual viral infection, as it can exhibit several clinical patterns [5] of dermatological manifestations. Unlike a previous study [20], a lot of our observed skin patterns did coexist in many of our patients.
As a whole, it could be stated that dermatological manifestations have a tendency to frequent more in patients with a severe/explosive disease course. The minimal presence of skin manifestation in mild/moderate COVID-19 cases that we report is consistent with a study in patients residing in the Tibetan plateau, where the disease course was generally mild in almost all patients [28].
The uniform and direct involvement of dermatologists/residents in the triage, admission, care as well as the search for skin manifestations at all times and levels in our study, may have translated into an accurate reporting of the incidence of these skin findings and their association with disease severity. Especially when a few previous attempts have either reported a highly skewed incidence of skin findings involving almost all the patients [29] or reported minimal involvement of skin where observation was done by nondermatological staff [30], others simply lacked photographic and/or histologic data [3].
The description of clinicopathologic features augments our existing knowledge on some of the patterns and provides an insight into the histology of cutaneous findings associated with COVID-19. Further structured clinical, molecular, serological, and histopathological studies are required to ascertain and explain the dermatological manifestations and their possible utilization for better management of the patients with COVID-19.

Conclusions
The majority of dermatological manifestations of COVID-19 such as perniosis, ischemia, livedo reticularis, and ecchymosis/purpura are more frequent in severe/explosive cases than other manifestations such as vesiculobullous, ecchymosis, and maculopapular exanthem in the older age group. Ischemic/gangrenous and vesiculobullous lesions herald a bad prognosis with high mortality. The presence of these dermatological manifestations could help set prognostic criteria in the future.
There is a possible connection of ecchymosis/purpura with COVID-19-induced thrombocytopenia. Histopathological features vary according to the skin lesions. They may be specific or nonspecific. Attention should be given to maintaining general skin health and hygiene in the prevention and treatment of non-COVID-19 related skin issues.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Ethical Committee Pak-Emirates Military Hospital Rawalpindi issued approval A/28/180/EC/2020. It is to certify that Dr Muhammad Anjum, FCPS-II trainee in Dermatology is submitting the research titled, "Dermatological Manifestations of Covid-19 in Pak-Emirates Military Hospital Rawalpindi". It has been scrutinized and found ethically sound as all ethical issues have been addressed in this study. Furthermore, there is no conflict of interest in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.